What is the treatment for acute pericarditis?

Treatment of Acute Pericarditis

First-line treatment for acute pericarditis consists of NSAIDs/Aspirin plus colchicine, with therapy continued until both symptoms resolve and CRP normalizes. 1

Initial Assessment and Risk Stratification

Acute pericarditis should be diagnosed when at least 2 of 4 criteria are present:

• Characteristic pleuritic chest pain
• Pericardial friction rub
• ECG changes (widespread ST elevation, PR depression)
• New or worsening pericardial effusion 1

Risk stratification is essential to determine management:

• High-risk features requiring hospitalization:
  • Fever >38°C (100.4°F)
  • Subacute onset
  • Large pericardial effusion (>20mm)
  • Cardiac tamponade
  • Failure to respond to NSAIDs within 7 days 2
  • Immunosuppression, trauma, or anticoagulant therapy 2
• Low-risk patients without these features can be managed as outpatients 2

First-Line Treatment

1. NSAIDs/Aspirin

• Ibuprofen: 600mg every 8 hours for 1-2 weeks 2, 1
• Aspirin: 750-1000mg every 8 hours for 1-2 weeks 2, 1
• Continue until symptoms resolve and CRP normalizes 1
• Taper by decreasing ibuprofen 200-400mg or aspirin 250-500mg every 1-2 weeks 2
• Use gastroprotection as needed 1

2. Colchicine (added to NSAIDs/Aspirin)

• Weight-based dosing:
  • <70kg: 0.5mg once daily
  • ≥70kg: 0.5mg twice daily 2, 1
• Continue for 3 months for first episode 1
• Reduces recurrence rates from 15-30% to 8-15% 1, 3
• Tapering not mandatory but may be considered in the last weeks 2

Second-Line Treatment

Corticosteroids

• Use only when:
  • NSAIDs/Aspirin contraindicated
  • Failure of first-line therapy
  • Specific indications (autoimmune diseases, pregnancy >20 weeks) 1, 4
• Dosing: Prednisone 0.2-0.5mg/kg/day 1
• Caution: Higher risk of recurrence with corticosteroid use, especially at high doses 1, 5
• When used, should be at low doses with very gradual tapering 5

Activity Restrictions

• Non-athletes: Restrict physical activity until symptoms resolve and CRP normalizes 2, 1
• Athletes: Restrict competitive sports for at least 3 months after normalization of symptoms, CRP, ECG, and echocardiogram 2, 1

Follow-up

• Initial follow-up 1-2 weeks after starting treatment 1
• Then every 1-2 months until treatment completion 1
• Monitor:
  • Symptom resolution
  • CRP normalization
  • ECG changes resolution
  • Resolution of pericardial effusion (if present) 1

Special Considerations

Etiology-Specific Treatment

• Idiopathic/viral: NSAIDs/Aspirin plus colchicine 1
• Tuberculous: Anti-tuberculosis therapy plus corticosteroids 1, 3
• Bacterial: Urgent drainage plus targeted antibiotics 1
• Neoplastic: Treatment of underlying cancer 1
• Uremic: Treatment of underlying renal failure 1

Common Pitfalls to Avoid

1. Inadequate NSAID dosing: Full anti-inflammatory doses every 8 hours are required 1
2. Premature discontinuation: Continue until both symptoms resolve AND CRP normalizes 1
3. First-line corticosteroid use: Avoid unless specifically indicated 1
4. Insufficient colchicine duration: Maintain for full recommended period 1
5. Missing high-risk features: Carefully assess need for hospitalization 2

Most patients with idiopathic/viral pericarditis have a good long-term prognosis when properly treated, with complications like constrictive pericarditis (<0.5%) and tamponade (<3%) being rare in these cases 1, 3.